APPLICATION FOR GROUP CRITICAL ILLNESS INSURANCE Evidence of Insurability

Unum Life Insurance Company of America (“Unum”) 2211CongressStreet•Portland,Maine04122 Application Type: NewlyEligible LateApplicant ReplaceExistingUnumCoverage ChangetoExistingCoverage Rehire SECTION 1: Employee (Applicant) Information – Always Complete

EmployeeName(First,Middle,Last) SocialSecurityNumber

HomeAddress(Street/POBox) Gender F MCity DateofBirth(mm/dd/yyyy)

State ZipCode HomePhone#

EmailAddress EmployeeID/Payroll#

EmployerName CustomerNumber DateofHire(mm/dd/yyyy)

St/POBox Occupation

City State ZipCode WorkPhone#

AreyouActivelyatWork? ScheduledNumberofWorkHours/week Yes No SECTION 2: Spouse Information – Complete Only if applying for Spouse Coverage

Name(First,Middle,Last) SocialSecurityNumber

Gender DoestheSpouseliveintheU.S.? Yes No DateofBirth(mm/dd/yyyy) F M If“No,”isyourSpouseaU.S.Citizen? Yes No

SECTION 3: Coverage Information – Complete for Employee (Applicant) and for Spouse (if applicable)

Employee Spouse (Applicant)

1. Haveyouoryourspouse(ifapplying)usedanytobaccoproducts(such ascigarettes,cigars,snuff,dip,cheworpipe)oranynicotinedelivery systeminthepast12months?.................................................................................. Yes No Yes No 2. WillcoverageappliedforreplaceormodifyanyexistingUnuminsurance coverage?................................................................................................................. Yes No Yes No If“Yes,”providedetailsbelow:

Insured’sName PolicyNumber

AE-1087-TN 1

AE-1087-TN 2

EmployeeName:________________________________________ EmployeeSSN:___________________________(Applicant) (Applicant)

SECTION 3: Coverage Information (continued)

3. Coverage Type Coverage Amount Cost Per Pay Period

a. GroupCriticalIllnessInsurance Employee $__________ Employee $__________ CriticalIllness Spouse $__________ Spouse $__________ or CriticalIllnesswithCancerb. WellnessBenefit $__________TotalCostPerPayPeriod............................................................................................................................... $__________

SECTION 4: Tier I Medical Profile – Complete as required for all underwritten coverage

Employee Spouse (Applicant) 1. Currentheightandweight ___ft.___in. ___ft.___in. ____lbs. ____lbs.

2. Haveyou(applicant)oryourspouse(ifapplying)testedpositivefortheHuman ImmunodeficiencyVirus(HIV)oritsantibodies,orbeendiagnosedwithorreceived treatmentforAcquiredImmuneDeficiencySyndrome(AIDS)?................................... Yes No Yes No

3. Inthepast10years,haveyouoryourspouse(ifapplying)receivedmedicaladvice, soughttreatment,includingmedication,orbeenhospitalizedforanyofthefollowing: Yes No Yes No

– Atrialfibrillation,angina,heartattack,coronaryarterydisease,heartsurgery, congestiveheartfailureorcardiomyopathy – ChronicObstructivePulmonaryDisease(COPD)oremphysema – CirrhosisoftheliverorHepatitisBorC – Diabetes(exceptgestationalordietcontrolled) – Glaucoma,retinitispigmentosaormaculardegeneration – Highbloodpressuretreatedwith3ormoremedications – Kidneydisease(excludingkidneystones)orfailure – Majororganfailure(liver,heart,lungorpancreas) – Stroke/TransientIschemicAttack(TIA)

4. Respondonlyifapplyingforcancercoverage: Inthepast10years,haveyouoryourspouse(ifapplying)beendiagnosed,received medicaladvice,soughttreatment,includingmedication,orbeenhospitalizedfor cancerormalignancyofanykind(includingcarcinomainsituandmelanoma), excludingbasalandsquamouscellcarcinoma?.......................................................... Yes No Yes No

EmployeeName:________________________________________ EmployeeSSN:___________________________(Applicant) (Applicant)

SECTION 5: Tier II Medical Profile – Complete if additional underwriting is required

Employee (Applicant)

1. Tothebestofyourknowledgeandbelief,haveanytwoofyournaturalparentsornatural siblings(sistersorbrothers)beendiagnosedwiththesamediseasebeforeage60based onthefollowinglist: a. Heartattackordisease,stroke,kidneydiseaseordiabetes................................................. Yes No

b. Respondonlyifapplyingforcancercoverage: – Cancer(excludingbasalcellcarcinomaandsquamouscellcarcinoma)....................... Yes No

2. Haveyoueverreceivedmedicaladvice,soughttreatment,includingmedication,orbeen hospitalizedforanyofthefollowing: a. – ChronicObstructivePulmonaryDisease(COPD),emphysemaorchroniclungdisease – CirrhosisoftheliverorHepatitisBorC – Diabetes(exceptgestational) – Heartattack,coronaryarterydisease,angina,orsurgeryontheheartorheartvalve(s) – Kidneydiseaseorfailure(excludingkidneystones,sponge,horseshoeorectopickidney andkidneyremovalduetotrauma) – Majororganfailure(liver,heart,lungorpancreas) – Peripheralvasculardisease – Stroke/TransientIschemicAttack(TIA).......................................................................... Yes No

b. Respondonlyifapplyingforcancercoverage: – Cancer(excludingbasalcellcarcinomaandsquamouscellcarcinoma)....................... Yes No

AE-1087-TN 3

EmployeeName:________________________________________ EmployeeSSN:___________________________(Applicant) (Applicant)

SECTION 6: Employee (Applicant) Statements

Iunderstandtheeffectivedateofcoverageissuedbasedonthisapplicationissubjecttotheapplicationbeingacceptableundertherules,limitsandstandardsofUnumLifeInsuranceCompanyofAmerica(hereafterUnum)andtheinsuranceis,orwouldhavebeen,issuedasappliedfor(orifnotissuedasappliedfor,thenasmodified).Theeffectivedateofapprovedcoveragewillbedeterminedassetforthinthecertificateofcoverageprovidedtome.IfIpaypartorallofthecostofmycoverage,theeffectivedatewillnotbeearlierthanthefirstofthemonthinwhichpayrolldeductionsbegin. Iauthorizemyemployertodeductthepremiumsforthisinsurancefrommyearnings(unlessthecoverageforwhichIamapplyingallowsforalternatemethodstopayinsurancepremiums). Allstatementsandanswersprovidedonthisapplicationaretrueandcomplete,andaregiventoobtaininsurance.

CAUTION:Unumwillrelyontheinformationprovidedinordertoevaluatethisapplication.Iftheanswersprovidedareincorrectoruntrue,Unummaydenybenefitsorrescindinsurance.

Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.

Employee(Applicant)Signature Date(mm/dd/yyyy)

UnumisaregisteredtrademarkandmarketingbrandofUnumGroupanditsinsuringsubsidiaries.TheinsuranceproductisunderwrittenbyUnumLifeInsuranceCompanyofAmerica.

AE-1087-TN 4